Sexual Healing by Dr. Margarita Kressin

Kyle and Linda came to the clinic for an appointment. They are a young, attractive couple and the problem they have is actually a relatively common one.

Dr.: How can I help you guys?

Kyle: I can’t please her sexually.

Dr.: Are your erections good.

K.: Yes.

Dr.: Hard, and they last as long as you want?

K.: Well, it goes away after I ejaculate.

Dr.: That’s normal.

Linda then interjects: But he comes too fast. Whoop ... we’re done.

Dr.: Within what time frame?

L.: 30 seconds. I looked it up on the Internet (because women look things up in the Internet) and I think he has premature ejaculation. Is it something I’m doing? Is it me?

Dr.: OK. Kyle, were you able to hold it longer with other partners?

K.: No, not really. Maybe I could go a minute at most.

Dr.: That time period still falls under premature ejaculation. You have what is called lifelong premature ejaculation. It is a fairly common condition occurring between 5 percent and 40 percent of sexually active men (Int J of Psychitr Med 1992). We think that there is actually a higher incidence in adolescents and young adults.

L.: Kyle has been my only partner. What is considered normal?

Dr.: One study that included five countries, using a stopwatch, showed most men ejaculate within 5.5 minutes. This is what we call IELT or intravaginal ejaculation latency time. Most men with PE ejaculate within a minute (0.9 min actually). And, Linda, it is not your fault, there is nothing you are doing that is causing this. The best thing you can do as a partner is be supportive as Kyle works through this.

K.: Is there something we can do?

Dr.: A standard approach is making sure you don’t have any physical and medical issues and also participating in cognitive and behavioral therapy. I will give you a name of a sex therapist and we will check and make sure you don’t have an underlying condition that may be the cause or contributing to this. And recently there have been some medications that we can try to see if we can work on prolonging your IELT. Let’s begin …

---

Andrew R. McCullough, MD, director of Male Sexual Health, Fertility and Microsurgery at the NYU Medical Center showed that men classified with probable premature ejaculation self-reported:

• poor control over ejaculation (50%)
• low satisfaction with sexual intercourse (23%)
• low satisfaction with sexual relationship (30%)
• low interest in actually having sexual intercourse (28%)
• difficulty in becoming sexually aroused (34%)
• difficulty relaxing during intercourse (31%)

Joe and his wife came to the our clinic, somewhat reluctantly. They have been having some issues in the bedroom.

Do you still get erections? I asked.

Yes!! Joe answered quickly. Then he turned to his wife, Don’t I?

Yeeeeeahhhhhhh? She answered.

Well….

I then asked the questions which let me know better whether he really is getting erections.

Do you get morning erections?

There is an Erection Hardness Scale:

0 — no erections at all
1 — some penile swelling
2 — gets hard, but not enough for penetration
3 — gets hard, and enough for penetration
4 — gets very hard

What number are you?
Does your erection last as long as you and your wife want it to?

He also filled out a SHIM questionnaire — a five item questionnaire that quantifies sexual function.

Here's a definition:
www.prostate-cancer.org/resource/gloss_s.html

And here's a link to the test:
http://www.urologychannel.com/HealthProfiler/healthpro_ed.shtml


A score of 21 or less means that erectile dysfunction (ED) needs to be addressed.

Joe’s score was 19.

Joe has ED.

This is Part II to my response on the recent Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html

It is my practice to measure testosterone levels on all my patients presenting with erectile dysfunction. We know that testosterone is needed for all sexual function from libido to erection to orgasm. Here I present evidence on the role of testosterone on erectile function. I will also address the claims that testosterone does not affect mood or energy levels or their bodies.

According to the article:

“... there is so little evidence to back up the claim that supplements … help men 45 and older buck up their sex lives, moods, energy levels or bodies.”

Here are some studies for you to consider.

Testosterone and sex lives:

Erectile dysfunction and testosterone deficiency.
Blute M, Hakimian P, Kashanian J, Shteynshluyger A, Lee M, Shabsigh R
Frontiers of Hormone Research. 37:108-22, 2009

Testosterone replacement alone in hypogonadal men can restore erectile function. A significant proportion of men who fail to respond to a PDE5 inhibitor are testosterone deficient. Testosterone replacement therapy can convert over half of these men into phosphodiesterase type 5 responders. It is now recommended that testosterone levels should be assessed in all patients with erectile dysfunction.

Endothelial effects of drugs designed to treat erectile dysfunction.
Aversa A, Caprio M, Rosano GM, Spera G
Current Pharmaceutical Design. 14(35):3768-78, 2008

… endothelial dysfunction is present in testosterone deficiency syndromes and replacement therapy is able to revert ED and to improve endothelial function.

Testosterone and mood

Effects of Testosterone Replacement in Middle-Aged Men With Dysthymia: A Randomized, Placebo-Controlled Clinical Trial
Seidman, Stuart N. MD; Orr, Guy MD; Raviv, Gil MD; Levi, Rachel BA; Roose, Steven P. MD; Kravitz, Efrat BSc; Amiaz, Revital MD; Weiser, Mark MD
Journal of Clinical Psychopharmacology
Issue: Volume 29(3), June 2009, pp 216-221

Testosterone replacement may be an effective antidepressant strategy for late-onset male dysthymia.

Comparison of long-acting testosterone undecanoate formulation versus testosterone enanthate on sexual function and mood in hypogonadal men.
Jockenhovel F., Minnemann T., Schubert M., Freude S., Hubler D., Schumann C., Christoph A., Ernst M.
European Journal of Endocrinology. 160(5):815-9, 2009 May.

Among the 12 items of subjective mood assessment, agitation, self-confidence, activation, good mood and concentration showed a significant improvement during the treatment and further significant improvement during follow-up with TU treatment. The other items, i.e. sociability, listlessness, dizziness, depression, fatigue, anxiety, and aggressivity, improved too, but not significantly. This tendency was the same during the follow-up with treatment with TU.

Partial androgen deficiency, depression and testosterone treatment in aging men.
Amore M, Scarlatti F, Quarta AL, Tagariello P
Aging-Clinical & Experimental Research. 21(1):1-8, 2009 Feb

Abstract: This study provides a critical review of the literature on depressive symptoms of partial androgen deficiency (PADAM) and their treatment with Testosterone (T). PADAM in aging males is responsible for a variety of behavioral symptoms, such as weakness, decreased libido and erectile dysfunction, lower psychological vitality, depressive mood, anxiety, insomnia, difficulty in concentrating, and memory impairment. The psychological and behavioural aspects of PADAM may overlap with signs and symptoms of major depression. Evidence of the relationship between androgen deficiency and male depression comes from studies that have assessed depression in hypogonadal subjects, the association between low T level and male depressive illness, and the antidepressant action of androgen replacement.

Although data derived from androgen treatment trials and androgen replacement do not support T treatment or replacement as more efficacious than placebo for major depressive disorder (MDD), the clinical impression is that, in some sub-threshold depressive syndromes, T may lead to antidepressant benefits.

Testosterone and bodies:

Low bone density and high percentage of body fat among men who were treated with androgen deprivation therapy for prostate carcinoma.
Chen Z, Maricic M, Nguyen P, Ahmann FR, Bruhn R, Dalkin BL.
Cancer. 2002;95: 2136 –2144

Chen et al (2002) investigated the effect of androgen deprivation (removing testosterone) on total body fat mass after 1–5 years of treatment in 62 men with prostate cancer. There was a significant increase in total body fat mass and reduction in lean body mass.

Effects of Testosterone Administration on Fat Distribution, Insulin Sensitivity, and Atherosclerosis Progression
Shalender Bhasin
Division of Endocrinology, Metabolism, and Molecular Medicine, Charles R. Drew University of Medicine Science, University of California — Los Angeles School of Medicine
Clinical Infectious Diseases 2003;37:S142–S149

In spite of the widespread belief that testosterone supplementation increases the risk of atherosclerotic heart disease, evidence to support this premise is lacking. Although supraphysiological doses of testosterone, such as those used by athletes and recreational body builders, decrease plasma high‐density lipoprotein (HDL) cholesterol concentrations, replacement doses of testosterone have had only a modest or no effect on plasma HDL in placebo‐controlled trials. In epidemiological studies, serum total and free testosterone concentrations have been inversely correlated with intra‐abdominal fat mass, risk of coronary artery disease, and type 2 diabetes mellitus. Testosterone administration to middle‐aged men is associated with decreased visceral fat and glucose concentrations and increased insulin sensitivity. Testosterone infusion increases coronary blood flow. Similarly, testosterone replacement retards atherogenesis in experimental models of atherosclerosis.

Testosterone and growth hormone improve body composition and muscle performance in older men.
Sattler FR., Castaneda-Sceppa C., Binder EF., Schroeder ET., Wang Y., Bhasin S., Kawakubo M., Stewart Y., Yarasheski KE., Ulloor J. Colletti P., Roubenoff R., Azen SP.
Journal of Clinical Endocrinology & Metabolism. 94(6):1991-2001, 2009 Jun.

Supplemental testosterone produced significant gains in total and appendicular lean mass, muscle strength, and aerobic endurance with significant reductions in whole-body and trunk fat.

The management of hypogonadism in aging male patients.
Sharma V, Perros P
Postgraduate Medicine. 121(1):113-21, 2009 Jan

Several studies indicate that testosterone replacement therapy may produce a wide range of benefits for men with hypogonadism, including improvement in libido, bone density, muscle mass, body composition, mood, and cognition.

---

The Journal Sentinel's claims that "one key problem is that there is a lack of scientific evidence that men over the age of 45 benefit from taking testosterone" is simply untrue. I have presented numerous articles in these posts, all based on scientific and medical research and publications disclaiming their assertion. It is unfortunate that patients are misguided by these articles. Patients should be cautious of what they read in the newspapers and they should always consult their physicians regarding their care and what they read before acting on their own.

---

The following is feedback received for this blog: Dr. K - Thanks for writing this rebuttal on that article. Do you know if middle-aged men can do something to increase T without having the actual hormone injections? Something "natural?" - Don Despite claims that the benefits of testosterone replacement therapy aren't supported by research, I have all the evidence I need. I use it myself and, believe me, it works. A daily dose of Testim 1% has significantly improved my sex drive and sexual function. It has given me a sense of mental clarity and accuity that many 50-something men seem to lack. It has dramatically raised my energy level and helped me to add lean muscle mass instead of fat. It may not be the fountain of youth, but it has improved the quality of my life, and that's good enough for me. - Kiernan B. Don, Yes, there have been studies that show increasing muscle mass can increase testosterone production. So start exercising and pumping iron! - Dr. Kressin

This is Part II to my response on the recent Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html


So the article also claimed that

“concerns that it may increase … cardiovascular disease”

Here I present articles published (364 articles matched), most of them within the last 9 months disputing this point. I didn’t have to go beyond the first page of my medline search to get these:

Endogenous testosterone and the prospective association with carotid atherosclerosis in men: the Tromsø study
Vikan T. Johnsen SH. Schirmer H. Njolstad I. Svartberg J. European Journal of Epidemiology. 24(6):289-95, 2009.

In the cross-sectional study, we found an inverse association between testosterone levels and total carotid plaque area (P < 0.05), after adjusting for age, systolic blood pressure, smoking and use of lipid-lowering drugs.

Androgens and cardiovascular disease.
Liu PY, Death AK, Handelsman DJ
Endocrine Reviews 2003 Jun;24(3):313-40

Observational studies show that blood testosterone concentrations are consistently lower among men with cardiovascular disease, suggesting a possible preventive role for testosterone therapy, which requires critical evaluation by further prospective studies. Short-term interventional studies show that testosterone produces a modest but consistent improvement in cardiac ischemia over placebo, comparable to the effects of existing antianginal drugs.

Reduced testosterone levels in males with lone atrial fibrillation.
Lai J, Zhou D, Xia S, Shang Y, Want L, Zheng L, Zhu J
Clinical Cardiology. 32(1):43-6, 2009 Jan

Mean levels of testosterone were significantly lower in subjects with lone atrial fibrillation when compared with controls (476 ng/dl versus 514 ng/dl, p = 0.005). CONCLUSION: Reduced testosterone levels may be associated with susceptibility to lone atrial fibrillation in men.

The dark side of testosterone deficiency: I. Metabolic syndrome and erectile dysfunction. [Review] [121 refs]
Traish AM. Guay A. Feeley R. Saad F.
Journal of Andrology. 30(1):10-22, 2009 Jan-Feb.

The metabolic syndrome (MetS) is considered the most important public health threat of the 21st century. This syndrome is characterized by a cluster of cardiovascular risk factors including increased central abdominal obesity, elevated triglycerides, reduced high-density lipoprotein, high blood pressure, increased fasting glucose, and hyperinsulinemia.

Central or abdominal obesity, measured as WC, is a classical feature of MetS and is associated with reduced total testosterone levels (Pasquali et al, 1997; Svartberg et al, 2004a,b, 2007; Osuna et al, 2006).

Other studies have confirmed the significant inverse correlation between total T and obesity (Pasquali et al, 1991; Laaksonen et al, 2003; Kalyani and Dobs, 2007). Therefore, men with visceral obesity are in a vicious cycle as T deficiency leads to reduced lipolysis, reduced metabolic rate, visceral fat deposition, and insulin resistance.

The dark side of testosterone deficiency: II. Type 2 diabetes and insulin resistance. [Review] [99 refs]
Traish AM. Saad F. Guay A.
Journal of Andrology. 30(1):23-32, 2009 Jan-Feb.

Low testosterone precedes elevated fasting insulin, glucose, and hemoglobin A1c (HbA1C) values and may even predict the onset of diabetes. Treatment of prostate cancer patients with surgical or medical castration exacerbates insulin resistance (IR) and glycemic control, strengthening the link between testosterone deficiency and onset of type 2 diabetes (T2D) and IR. Androgen therapy of hypogonadal men improves insulin sensitivity, fasting glucose, and HbA1c levels. We suggest that androgen deficiency is associated with IR, T2D, MetS, and with increased deposition of visceral fat, which serves as an endocrine organ, producing inflammatory cytokines and thus promoting endothelial dysfunction and vascular disease.

The dark side of testosterone deficiency: III. Cardiovascular disease. [Review] [99 refs]
Traish AM. Saad F. Feeley RJ. Guay A.
Journal of Andrology. 30(1):23-32, 2009 Jan-Feb.

Androgen deficiency is associated with increased levels of total cholesterol, low-density lipoprotein, increased production of proinflammatory factors, and increased thickness of the arterial wall and contributes to endothelial dysfunction. Testosterone supplementation restores arterial vasoreactivity; reduces proinflammatory cytokines, total cholesterol, and triglyceride levels; and improves endothelial function but also might reduce high-density lipoprotein levels.

And finally a few others in summary:

• Diaz-Arnjonilla, et al Intl J of Impot Res 2009 —
  
  • Low T in obese men
  • Lot T in men with metab syn and DM
  • BMI inv propor to serum total T
• Schandt et al Current Opinion in Urology 2009 — Link of androgen deprivation therapy in prostate cancer to development of metabolic syndrome
• Corona et al J of Sex Med 2008 — Low levels of androgens in men with erectile dysfunction and obesity
• Dandona P et al Postgrad Medicine 2009—
  • Hypogonadotropic hypogonad seen in DM2 is assoc with obesity but not duration of DM2
  • 1/3 of DM2 have low T

Two patients of mine recently asked me about the Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html

One of them actually stopped it because he became very concerned about T after reading the article. One of them asked me if he should stop it.

So, I was asked to write about this as I do prescribe testosterone, and I want to help ease the potential fears created by this article. Because of the detail of the article and the rebuttal of many points, I thought I would break it into three parts so the important points are not missed. The other two posts will come in the next few days.

I will quote the article and then cite articles that counter the point:

“... concerns that it may increase the risk of prostate cancer…”

1. "The relationship between total and free serum testosterone and the risk of prostate cancer and tumour aggressiveness."
   
   Morote J. Ramirez C. Gomez E. Planas J. Raventos CX. de Torres IM. Catalan R.
   BJU International. 104(4):486-9, 2009 Aug.
   
   CONCLUSION: Prostate cancer risk and tumour aggressiveness are not related to serum levels of total and free testosterone, but hypogonadal patients do not have a greater risk of prostate cancer and tumour aggressiveness.
   
   
2. "Pretreatment serum testosterone and androgen deprivation: effect on disease recurrence and overall survival in prostate cancer patients treated with brachytherapy."
   
   Taira AV. Merrick GS. Galbreath RW. Butler WM. Wallner KE. Allen ZA. Lief JH. Adamovich E.
   International Journal of Radiation Oncology, Biology, Physics. 74(4):1143-9, 2009 Jul 15.
   
   CONCLUSION: Low pretreatment testosterone levels alone did not affect disease recurrence or overall survival. Patients with baseline low testosterone who also were treated with androgen deprivation therapy had a trend toward decreased overall survival.
   
   
3. "Testosterone therapy in hypogonadal men and potential prostate cancer risk: a systematic review."
   
   Shabsigh R, Crawford ED, Nehra A, Slawin KM
   International Journal of Impotence Research. 21(1):9-23, 2009 Jan-Feb.
   
   CONCLUSION: Of studies that met inclusion criteria, none demonstrated that testosterone therapy for hypogonadism increased prostate cancer risk or increased Gleason grade of cancer detected in treated vs. untreated men. Testosterone therapy did not have a consistent effect on prostate-specific antigen levels.
   
   
4. "Testosterone Therapy in Men With Prostate Cancer: Scientific and Ethical Considerations"
   
   Abraham Morgentaler
   Journal of Urology 181 (3):972-79, 2009 Mar.
   
   CONCLUSION: Although no controlled studies have been performed to date to document the safety of testosterone therapy in men with prostate cancer, the limited available evidence suggests that such treatment may not pose an undue risk of prostate cancer recurrence or progression.

Also there have been active research studies in supplementing men with low testosterone who had prostate cancer. If we really thought that T caused prostate cancer, we would never even consider this. These original research studies by some of the leading urologists in the country and the world were presented in the 2008 meeting of the Sexual Medicine Society of North America:

1. "Testosterone therapy in men with untreated porstate cancer on active surveillance"
   
   Morgentaler A, Bennet R, Mohamed O, Chan R, Khera M, LIpshults L
   
   CONCLUSION: Testosterone therapy in 13 hypogonadal men with untreated prostate cancer for a mean of 12 months was not associated with an increase in PSA or substantial rate of grade progression on repaeat prostate needle biopsy. These pilot results suggest that testosterone therapy may be cautiously considered in men with low-risk untreated prostate cancer.
   
   
2. "Testosterone replacement therapy following radical prostatectomy"
   
   Khera M, Grober E, Najari B, Mohmed O, Colen J, Lamb, D, Lipshultz L
   
   CONCLUSION: Testosterone replacement therapy (TRT) is effective in improving testosterone levels in hypogonadal men following radical prostatectomy (RP). In this cohort of hypoogonadal men on TRT after RP there was a significant rise in testosterone values with no significant rise in PSA following TRT.
   
   
3. "Analysis of the PSA response after initiating testosterone supplementation (TS) in patients who have previously received management for their localized prostate cancer"
   
   Davila H, Arison C, Hall M, Salup R, Lockhart J, Carrion R
   
   CONCLUSION: TS by T injection or transdermal gel is effective in improving T level in men following RP and external beam radiation therapy. No significant differences were noted between these groups with regard to PSA levels after TS. This pilot study confirmed consistent efficacy and safety concerning the use of TS after prostate cancer therapy, regardless they type of cancer treatment.

These are just articles within the last year. The urologic community has shifted its thinking on the relationship of testosterone and prostate cancer. The newspaper article did not show or quote any scientific studies. I hope that these studies in our medical and scientific literature can allay some of the questions and fears with testosterone replacement and prostate cancer risk.